Summary: There was fault by the Council in the late Mrs Y’s care in one of its care homes. The care home did not consult with Mrs Y’s GP to see if her medicine could be administered to her covertly and her care plans did not include detailed information about how to deliver personal and oral care in her best interests. This caused Mrs Y avoidable distress which cannot now be remedied as she has died. The Council will apologise and make a symbolic payment to her daughter Ms X (and for other family members) to recognise her distress in witnessing her mother receiving poor care. The Council will take action to minimise the risk of recurrence.

The complaint

1. Ms X complained about her late mother Mrs Y’s care in Valley View Court Care Home (the Care Home) owned by the Council. Ms X complained about inadequate care around food and fluid, personal care, oral care and medication.
2. Ms X said the Care Home’s poor service caused her and Mrs Y avoidable distress.

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The Ombudsman’s role and powers

3. We investigate complaints about ‘maladministration’ and ‘service failure’. In this statement, I have used the word fault to refer to these. We must also consider whether any fault has had an adverse impact on the person making the complaint. I refer to this as ‘injustice’. If there has been fault which has caused significant injustice, or that could cause injustice to others in the future we may suggest a remedy. (Local Government Act 1974, sections 26(1) and 26A(1), as amended)
4. If we are satisfied with an organisation’s actions or proposed actions, we can complete our investigation and issue a decision statement. (Local Government Act 1974, section 30(1B) and 34H(1), as amended)
5. Under our information sharing agreement, we will share this decision with the Care Quality Commission (CQC).

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How I considered this complaint

6. I considered evidence provided by Ms X and the Council as well as relevant law, policy and guidance.
7. The parties had an opportunity to comment on my draft decision. I considered any comments before making a final decision.

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What I found

Relevant law and guidance

8. The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (the Regulations) set out the requirements for safety and quality in care provision. The Care Quality Commission (CQC) issued guidance in March 2015 on meeting the regulations (the Fundamental Standards.) The Ombudsman considers the 2014 Regulations and the Fundamental Standards when determining complaints about poor standards of care. Those relevant to this complaint are:
• Regulation 9: care and treatment should be appropriate, to meet a person’s needs and to reflect their preferences. Care providers should carry out an assessment of needs and preferences and design a care plan to meet needs and preferences.
• Regulation 14: the nutrition and hydration needs of residents must be met. They must receive suitable nutritious food and fluid to sustain life and good health, with support to eat and drink if needed.
• Regulation 12(i): care should be delivered in a safe way including by working with health professionals to ensure the health and welfare of residents.
• Regulation 11: care and treatment can only be given with the consent of the relevant person. If the person is unable to give consent because they lack capacity to do so, the care provider must act in line with the Mental Capacity Act 2005.
9. The Mental Capacity Act and Code of Practice to the Act sets out the principles for making decisions for adults who lack mental capacity. An assessment of a person’s mental capacity is required where their capacity is in doubt (Code of Practice paragraph 4.34)
10. A person lacks mental capacity to make a decision if they have a temporary or permanent impairment or disturbance of the brain or mind and they cannot make a specific decision because they are unable to:
• Understand and retain relevant information or
• Weigh that information as part of the decision-making process or
• Communicate the decision (whether by talking using sign language or other means.) (Mental Capacity Act, section 3)
11. Where a person lacks capacity to make a decision, any decision made on their behalf should be taken in their best interests.
12. When dealing with adults who lack capacity to make decisions about their care, councils should consult and take into account the views of: people the person has named to consult; carers; their attorney or deputy. Generally, councils consult about care and support plans by holding a best interests meeting involving relevant people.
13. Normally councils decide whether to meet an adult’s needs for care and support after carrying out a social care assessment. In urgent cases, they can meet needs before completing an assessment (Care Act 2014, section 19(3))
14. Intermediate care is a structured programme of care provided for a limited time. (Care and Support Statutory Guidance Paragraphs 2.12 to 14)
15. Discharge to Assess services are temporary placements in care homes which enable health and social care professionals to assess a person’s long-term health and care needs and develop a care plan to decide on the most appropriate care for a person whose needs are not clear.

What happened

16. Mrs Y had dementia. She was living at home with her husband Mr Y before she went into the Care Home and he was providing all her care. There were concerns about Mr Y’s capacity to continue caring for Mrs Y due to ongoing lack of sleep. The Council’s records indicate Mrs Y’s case was an urgent one.
17. A social worker visited Mr and Mrs Y in December 2024 and spoke about Mrs Y going to a day centre and about respite care. The social worker was concerned for Mr Y’s mental wellbeing and the pressures of the caring role. A different social worker carried out an assessment of Mrs Y’s mental capacity to decide to go into short term residential care. She could not understand or retain information needed to make the decision and so lacked capacity.
18. The Council offered Mrs Y a place in the Care Home in January 2025. This was a temporary assessment bed under Discharge to Assess services (see paragraph 15). The aim was to carry out a full assessment of Mrs Y’s needs to decide what care she needed long-term. The social worker completed a basic assessment which said Mrs Y needed full support with all personal care, could not wash or dress or brush her teeth or hair independently. She could go to the toilet independently. She had a small appetite and would graze.
19. The Care Home drew up a ‘recovery plan’ for Mrs Y. It said:
• She moved independently
• She could not make meals or drinks, but she could eat on her own. The plan noted her favourite foods. She took small portions and did not like to sit at a table. Staff would offer food little and often
• She mostly declined medication
• She did not like being alone at night and was anxious around going to bed. She preferred to sleep in a chair in the lounge.
• She regularly declined support around personal care and dressing. Staff would encourage her to accept support.
20. The Care Home kept daily records of the care given or offered to Mrs Y during her three-week stay. In summary:
• She always refused to take her prescribed medicines
• She was often walking around the unit
• She was restless at night, staff tried to settle her in her room, but she was a light sleeper and would often wake once they left her. She often slept in a comfortable chair in the lounge area
• Her fluid intake was poor in the last week of her stay. This was noted and staff sought advice from her GP. The notes said staff were to prompt her to drink.
• Staff consulted with the local NHS digital care hub on several occasions. (The digital care hub provides clinical support to care homes in Bradford)
• The GP and mental health team were consulted and saw Mrs Y. The GP prescribed antibiotics for a suspected urine infection. Mrs Y was also seen by paramedics when she complained of stomach pain and the GP examined a lump.
• The food charts show a variable dietary intake. Staff offered favourite foods including pineapple and finger foods like crumpets. Food and fluids were offered and taken at frequent times throughout the day and snacks at night.
• There are very few records of staff giving personal care or offering it and Mrs Y refusing. On several occasions, family provided Mrs Y’s personal care
21. Ms X complained to the Council about the same matters raised with us. The Council did not uphold the complaint. So Ms X complained to us.

Findings

Nutritional care

22. The Care Home kept detailed records of fluid intake and took appropriate action by referring Mrs Y to health professionals (the digital hub, the GP and the mental health team) when concerned about low fluid intake. The recovery plan indicates Mrs Y had a small appetite. The Care Home kept detailed records of food offered and how much she ate and drank. Mrs Y was offered food and fluid in line with her preferences. Care was in line with Regulations 9, 14 and 12(i) and there is no fault.

Personal and oral care

23. There is no record of staff offering personal or oral care to Mrs Y. This is not in line with Regulations 9 and 11 and there is fault. I would expect the recovery plan (which is a basic care plan) to have been updated during Mrs Y’s stay as information emerged about how best to approach her and different methods likely to mean she would accept care. The plan should have included detailed information and advice for staff about what to do if Mrs Y kept on declining personal care and a detailed plan to ensure basic needs were met around dignity notwithstanding a lack of consent. Such decisions should have been made within the Mental Capacity Act framework. The available records indicate Mrs Y did not have her dentures cleaned during her three-week stay and that no attempts at bathing or showering were offered or successful. This was fault causing avoidable Mrs Y avoidable distress. Mrs X also suffered distress as a close relative witnessing her mother’s lack of dignity.

Medication

24. Mrs Y declined all her medication for the whole of her stay at the Care Home. This included a course of antibiotics to treat a suspected urine infection. There was no consultation with the GP around whether it was in Mrs Y’s best interests to receive medication covertly (for example, by disguising it in her food). Care was not in line with Regulations 12(i), 9 or 11 and this was fault likely to have caused avoidable distress as Mrs Y did not have the benefit of those prescribed medicines.

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Agreed Action

25. Mrs Y has died since the actions which led to her family complaining. We would not recommend a payment to her estate to recognise Mrs Y’s distress as this was personal to her.
26. Within one month of my final decision, the Council will complete the following actions:
1. A written apology to Mrs X and a symbolic payment of £200 to reflect the avoidable distress of witnessing poor care. We publish guidance on remedies which sets out our expectations for how organisations should apologise effectively to remedy injustice. The organisation should consider this guidance in making the apology I have recommended in my findings.
2. A written reminder to the Care Home’s management about care for new residents/those residents in assessment beds who lack mental capacity to:
1. Update care plans to include more detailed information on how to provide care to residents who lack capacity and who do not consent to personal care
2. Involve a resident’s GP or other healthcare professional for advice about covert administration of medicine where a resident repeatedly refuses to take prescribed medicines.
27. The Council should provide us with evidence it has complied with the above actions.

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Decision

28. I find fault causing injustice. The Council had agreed actions to remedy the injustice.

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Investigator's decision on behalf of the Ombudsman